This intervention to rapidly re-house people with HIV was implemented at multiple New York City shelters and was associated with significant improvements in viral suppression.
Evidence-Based Intervention
People who are unstably housed
Viral suppression; Beyond the care continuum
Support service delivery model
The RWHAP Part F SPNS program funded the Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations initiative from 2012–2017, to provide coordinated housing supports and HIV, behavioral and mental health care to people experiencing homelessness. Nine funded demonstration sites created partnerships with housing providers, integrated behavioral health and HIV care, and provided intensive patient navigator services. A multi-demonstration site evaluation found that, compared to baseline, participants were more likely to be virally suppressed after 12 months in the intervention.
Evidence-Based Intervention
People who are unstably housed
Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression; Beyond the care continuum
Support service delivery model
Pasadena, San Diego County, San Francisco, CA
New Haven, CT
Jacksonville, FL
Cumberland, Hoke, Harnett, Johnston, and Sampson Counties, NC
Multnomah County, OR
Dallas and Harris Counties, TX
The Max Clinic, located within the University of Washington’s Harborview Medical Center complex in Seattle, offers walk-in services and incentives to clients reengaging in HIV care, especially those who have not been well served by the traditional health care model—including clients who are experiencing homelessness, or who have mental health and substance use issues. The Max Clinic offers rapid antiretroviral therapy, incentives, a flexible clinical model, and access to comprehensive support services. Max Clinic clients were significantly more likely to reach viral suppression after 12 months than a comparable control group.
Evidence-Based Intervention
People with HIV who are not in care
Clinical service delivery model
This data-to-care (D2C) initiative, implemented by the San Francisco Department of Public Health and its affiliated clinics from 2015–2017, used three sources of data to identify people not in care: HIV surveillance data, healthcare provider referrals, and electronic health record (EHR) data. LINCS navigators then used disease intervention searching tools and EHR data to locate clients and connect them to an HIV care provider. LINCS navigators followed up with clients for 90 days to support engagement in care. LINCS participants were more likely to be retained in care and virally suppressed after the intervention than before.
Evidence-Based Intervention
People with HIV who are not in care
Retention in HIV medical care; Viral suppression
Outreach and reengagement activities; Data utilization approach
Five clinics implemented Tailored Motivational Interviewing (TMI) to better serve young people with HIV as part of a RWHAP Part F SPNS initiative. Motivational interviewing is a well-documented approach to engage youth in care and facilitate behavior change in a variety of contexts. Clients participating in TMI received integrated HIV medical care and TMI, and demonstrated improved engagement in care and health outcomes.
Evidence-Based Intervention
Support service delivery model
Los Angeles, CA
Ft. Lauderdale, FL
Baltimore, MD
Detroit, MI
Philadelphia, PA
LINK LA is a 12-session, 24-week peer navigation intervention for people with HIV who are scheduled to be released from incarceration. LINK LA peer navigators focus on behavioral changes that promote medication adherence and retention in care, while providing social support and facilitating communication with medical providers. LINK LA showed improvements in linkage to and retention in HIV care and viral suppression among people with HIV re-entering the community after incarceration.
Evidence-Based Intervention
People who are justice involved
Linkage to HIV medical care; Retention in HIV medical care; Viral suppression
Outreach and reengagement activities; Support service delivery model
Seeking Safety helps people who have experienced trauma and/or substance use disorder gain safe coping skills through a flexible 12-session intervention. The University of California, San Diego Mother Child Adolescent HIV Program and the Multicultural AIDS Coalition implemented Seeking Safety as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Participants had higher rates of retention in care and viral suppression after 12 months of the intervention.
Evidence-Based Intervention
People with a history of trauma; People with substance use disorder
Retention in HIV medical care; Viral suppression
Support service delivery model
Collaborative Care Management (CoCM) integrates mental health and primary care, with a care team of a primary care provider, behavioral health care manager, and psychiatric consultant. Together they provide comprehensive and coordinated care to people with HIV who have co-occurring depression or other psychiatric disorders. Four sites implemented CoCM as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. CoCM led to statistically significant increases in antiretroviral therapy (ART) prescription and viral suppression.
Evidence-Based Intervention
People with diagnosed mental illness
Prescription of antiretroviral therapy; Retention in HIV medical care; Viral suppression
Clinical service delivery model
Washington, DC
Baton Rouge, LA
Detroit, MI
Tulsa, OK
Tailored Motivational Interviewing (TMI) delivers brief motivational interviewing counseling sessions customized to encourage people with HIV to engage in HIV care, take HIV medications as prescribed, and improve other health-related behaviors. Three sites implemented TMI as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017 to 2021. Clients who participated in TMI had significant improvement in engagement in care, prescription of antiretroviral therapy, retention in care, and viral suppression.
Evidence-Based Intervention
Black/African American people; Gay, bisexual, and other men who have sex with men (MSM); Youth ages 13 to 24; Young adults ages 25 to 34
Linkage to HIV medical care; Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Support service delivery model
Fort Lauderdale, FL
Macon, GA
Jackson, MS
PositiveLinks is a mobile platform deployed by clinics or community-based organizations to connect people with HIV to a digital support community. The client-facing app helps people with a new diagnosis of HIV become engaged in care and helps people at risk of being lost to care overcome barriers related to geographic or social isolation. From the app, people can access Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant patient dashboards, secure messaging, and patient lab records. People who used PositiveLinks had increased rates of retention in care and viral suppression.
Evidence-Based Intervention
People with a new diagnosis of HIV; People living in rural areas
Retention in HIV medical care; Viral suppression
Use of technology and mobile health